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Empowering our community through holistic, cultural, somatic, and systematic support.
Referring Party Information
Date of referral
*
/
Month
/
Day
Year
Date
Is this a referral for compressive assessment or SUD IOP treatment in-person/virtual?
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Comprehensive Assessment
SUD IOP Treatment - In-Person
SUD IOP Treatment - Virtual
Name of Referring Provider/Agency
*
Contact Person
*
Phone Number
*
Email
*
example@example.com
Address
*
Relationship to client:
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Primary Care Provider
Social Worker
Court
Self-referral
Other
Will there be a ROI attached to allow us to update you? (if yes, please upload at the end of the referral form)
*
Yes
No
Is there a current/recent diagnostic assessment available?
*
Yes
No
How did you hear about us
*
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Client Information
Full Name
*
Date of Birth
*
/
Month
/
Day
Year
Date
Social Security Number
*
Gender Identity:
*
Female
Male
Transgender
Non-Binary
Genderqueer
Other
Race/Ethnicity
*
Phone Number
*
Email Address
*
example@example.com
Best time to call:
*
Mornings
Afternoons
Evenings
Preferred Method of Contact:
*
Email
Text
Calls
Reside on reservation?
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Yes
No
Eligible for Indian Health Services?
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Yes
No
Address
*
Address type?
*
Client's
Parent/Guardian
Foster Home
Shelter
Group Home
Other
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Service Needs & Primary Concerns
Primary concerns
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Depression
Anxiety
Post-Traumatic Stress Disorder
Psychosis
Autism Spectrum Disorder
Aggression
Behavorial Concerns - Home
Behavorial Concerns - Work
Suicidal Ideation
Homicidal Ideation
History of Suicide Attemps
Self-Injurious Behavior
Recent Life Transtition/Adjustment
Parenting Challenges
Anger Management
Emotional Regulation/Coping
Child Abuse - Survivor
Child Abuse - Perpetrator
Intimate Partner Violence - Survivor
Intimate Partner Violence - Perpetrator
Intimate Partner Violence - Child Witness
History of Sexual Assault/Abuse
Learning/School Skills Concerns
Other
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Substance Use & Treatment History
Last Use Date
*
/
Month
/
Day
Year
Date
Primary Substance Use
*
Previous Treatment History (rehab, detox, outpatient, inpatient,)
*
History of overdose:
*
Yes
No
Risk factors:
*
Suicidal Ideation
Self-harm
Homelessness
Legal Issues
Other
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Psychosocial & Environmental Factors
Living situation:
*
Stable Housing
Homeless
Group Home
Transitional Housing
Other
Employment status:
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Employed
Umemployed
Student
Other
Legal Involvment
*
Court Ordered
Probation
Parole
None
Family & Social Support System:
*
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Insurance & Financial Information
Insurance Provider
*
Is this commercial insurance?
*
Yes
No
Member ID or PMI
*
Group Number
*
You may upload file attachments below. Please include the following, if applicable: Diagnostic Assessment, CHIPS petition, Release of Information, Court Orders, etc.
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Please provide any additional information you think we should have to facilitate this referral
ClientGuardianReferring Provider Signature
*
Date
*
/
Month
/
Day
Year
Date
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